Camp Ta Ta Pochon

Departure: st Saturday, July 21 , 2012 at 8:00 a.m. Return: th Saturday, July 28 , 2012 at 3:00 p.m. Cost Before May 15th: $275.00 After May 15th: $295.00

YMCA of West San Gabriel Valley 401 Corto Street, Alhambra, California 91801 Tel (626) 576-0225 Fax (626) 576-1351 www.wsgvymca.org The mission and Purpose of the West San Gabriel Valley YMCA is to put Christian principles into practice through programs that build a healthy spirit, mind, and body for all.

YMCA of West San Gabriel Valley Camp Ta Ta Pochon Youth Camp REGISTRATION PACKET CHECK LIST Camper Name:________________ Registration Date:___________________ Rally night is Tuesday, before the 1st day of the Camp Session. Come and meet the camp counselors and directors and obtain current information before sending your child(ren) to camp. Please assist the YMCA and Camp Ta Ta Pochon staff by reading all of the instructions on the forms carefully before filling out the forms. Complete all the forms giving us as much information on your child as necessary to help the camp staff to work better with your child. Please print and use ink when filling out these forms. Please mail the completed forms to the YMCA of West San Gabriel Valley at 401 East Corto Street, Alhambra, California, 91801. Call the YMCA at (626)576-0226 if you have any questions regarding this registration packet. 1. Camp fills up on a first come first serve basis. Please turn in your complete packet ASAP. All packets and payments must be turned in by camp rally night on the Tuesday, before the first day of the Camp Session. 2. The Health Examination form must be filled out by the Doctor’s office. The health examination form must also be signed by the child’s health practitioner and have the medical office stamp. To assist your child’s health practitioner, please bring the health history form with you to the medical office. 3. Did you and your child(ren) sign all the required fields? This checklist is to help you to double check everything before sending it back to us. *Circle the “YES” when the required signatures are done. “X” each item when it is double-checked under the “FILLED OUT COMPETELY” column. TEM# FORM SIGNATURE SIGNATURE SIGNATURE SIGNATURE CAMPER’S Form YMCA REQUIRED REQUIRED REQUIRED Photo REQUIRED Filled out STAFF Parent Camper Licensed Medical Stamp Release completely INITIAL Guardian Personnel Initialed Yes 1 Summer Youth Camp Registration Form Program Payment (Prin 2 Camper’s Last and First name)

3 4 5 6 7 8 9

Camper information Form Emergency/Insurance Form Health History Form Health Examination Form Acknowledgement of Risks Parent/Camper Confidential form Pick up Authorization & Camper Profile

Yes Yes

Yes: if limits apply

Yes

Yes

Yes

Yes

Yes

Yes

Yes

IMPORTANT!!

FINANCIAL ASSISTANCE

Remember, the following items must be turned in on or before your Rally Night date: 1. Health Examination Form (Complete and Signed)

The YMCA offers a program to help families with the investment of a camp experience for their camper(s). YMCA “Camperships” are made possible by charitable donations. “Campership” applications can be obtained through the YMCA by calling (626)576-0226

2. Health History Form (Completed, signed, and stamped by a physician) 3. Camper Information Form 4. Balance of Camp Fee

Camp Ta Ta Pochon Youth Camp Registration Form Registration Date:________________ Return to YMCA of West San Gabriel Valley 401 E. Corto Street Alhambra, CA 91801 Summer Youth Camp Ages 8 – 15 (includes a photo and a t-shirt)

Dates: July 21st- 28th (Sat – Sat) Fee After May 15th: $295.00 Before May 15th: $275.00

Summer CIT Program:Ages 16 – 17

Fee: $150.00

Rally Night Tuesday July 17th from 6:00 p.m. to 7:30 p.m. Affiliated with Following Agency: (DCFS, Options, etc.) ________________________ Please Print Clearly: Camper Name:______________________ Age:____ DOB:____________ Gender:_____ Address:_________________________ City/State:________________ Zip Code:______ Home Address:_____________________ Cell Phone:________________________ Parent or Guardian’s Name:____________________ Email Address:________________ Cabin Buddy Preference:____________________________ Cabin Buddy Age:________ (Cabin buddies must be no more than one year apart. The YMCA does not guarantee camper and buddy will be assigned to the same cabin.)

A $50.00 non-refundable deposit must accompany this registration form. YMCA CAMPING PROGRAMS ARE OPEN TO ALL PERSONS REGARDLESS OF RACE, RELIGION, COLOR, SEX, AGE, NATIONAL ORIGIN, HANDICAP, OR ABILITY TO PAY. Parent/Guardian Please read and sign: I, the undersigned parent/legal guardian of the above minor, give permission for the minor to participate in the YMCA program described in the 2012 Youth Camp Season program brochure. The minor is physically able and mentally prepared to participate in all activities as described in the announcement of the camp program. I understand that certain hazards and dangers are inherent in the camp program and activities. I thereby, voluntarily and knowingly assume all risk and dangers inherent and incidental to the activities of the program. I agree to have the health examination form competed by a licensed physician within 12 months prior to the beginning of the camp session. I agree to comply with all other policies and procedures described in the accompanying registration literature. I agree to pay any balance due of the camp fee no later than one week prior to the beginning of the camp session reserved. Camp fees are not refundable without a physician’s authorized medical reason. I understand that no refunds are given if a child leaves early because of homesickness or for disruptive behavior as decided by the camp director and that the deposit is not refundable for any reason. I also authorize the YMCA to have and use photographs, slides, and video tapes of the person named on this registration as may be needed for its public relations and promotional programs.”

Important: Parent / Guardian’s Signature (Required) : _____________________ Date: __________ Print Name:__________________________

Acknowledgement of Risks Child’s Name (Please print) __________________________ ACKNOWLEDGEMENT OF RISKS I understand that there are numerous risks associated with participation in any camping activities, including hiking, backpacking, out camping, archery, riflery, rope courses, technical climbing, river rafting, mountain biking, crafts and transportation to and from camp activities, These risks, which contribute to the unique nature, character, and desirability of the activities involved, may pose the possibility of physical injury, illness, or death. I further understand that the activities involved will take place in an outdoor environment in mountainous terrain. For this and other reasons, the risk cannot be eliminated, altered or controlled. Some, but not all, of the specific risks include: Weather conditions which may change rapidly and unpredictably and may cause injury directly (for example, rain or hail storms, sunburn, lightning strikes, cold temperatures and the lake) or by acting upon the factors (for example, performance of equipment may be impaired by weather conditions). Equipment used in the activity may break, fail or malfunction despite reasonable maintenance and use. Some of the equipment used in activities may inflict injuries even when used as intended. Persons using equipment may lose control of such equipment and cause injury to themselves and to others. Most activities take place in natural environment where unexpected, unseen and unmarked objects and conditions create risk of injury or death from falling, tripping, slipping, insect or animal contact, unstable surface conditions, falling rocks and objects, potentially harmful vegetation and the like. Activities near or in the water, such as rafting, swimming, snorkeling, kayaking, canoeing, surfing, boogie boarding, fishing, hiking, horseback riding, and the like, involve risk of injury, illness or drowning. Because these activities are in the natural environment, oceans, lakes, ponds, streams, rivers and creek present risks of water movement, subsurface conditions, cold water temperatures, water impurities, and the like. In addition, there is a risk of falling out of or being struck by watercraft. Counselors and guides use their best judgment in determining how to react to circumstance, including weather, terrain, water conditions and other unpredictable natural phenomena, the counselors and guides cannot guarantee such circumstances, and individual’s capabilities and the like. Motor vehicle accidents may occur in the course of transporting camp participants to or from other activities. These are some, but not all, of the risks inherent in camping activities; a complete listing of risks is not possible. In addition, there are risks, which cannot be anticipated. I GIVE PERMISSION for my child to participate in all camping activities, including those described above. I acknowledge and assume the risks involved in these activities, and for any damage, illness, injury or death resulting from such risks. There are no physical, emotional or mental problems or limitations associated with participation in camp activities except as disclosed by me in writing to the YMCA of West San Gabriel Valley. ___________________________

____________________________________ _________________

Parent/Guardian Print Name

Parent/Guardian Signature

Date

Pick up Authorization and Camper Profile: I authorize the following adults to pick up my child(ren) at any time. Additionally, I authorize the YMCA of West San Gabriel Valley to contact any of these adults in case of emergency. I have contacted all adults listed here and they are ready, willing, and able to assist with the care of my child(ren) should be unable to do so. The following adults must show a current picture ID in order to sign on behalf of me. Name:

Phone Number:

Relationship to Child:

1.____________________________________________________________________________ 2.____________________________________________________________________________ 3.____________________________________________________________________________ 4.____________________________________________________________________________ 5.____________________________________________________________________________

_______________________________________ Parent/Guardian Please PRINT Name:

________________________________ Parent/Guardian Signature:

_________________ Date: Camper Identification: Name:__________________

Place Camper Photo Here

Birth Date:_________ Age:_______ Height:___________ Weight______ Eye Color_______ Hair Color_____ T-Shirt Size :____________

Photo Release (Initial Below) _____I hereby give consent to YMCA of West San Gabriel use of video or still images of my child for promotional purposes. _____I DO NOT give consent to the YMCA of West San Valley use of video or still Images of my child for promotional purposes.

Consent to Search: In order to prevent harm, maintain order to campers and staff who are participating in YMCA of West San Gabriel Valley’s Camping activities, I hereby give permission to the YMCA Director of Camping Services to search my child’s personal belongings when there is reasonable suspicion that the camper has possession of illegal or dangerous items (i.e. weapons, knives, alcohol, illegal drugs, fireworks or explosives) or the camper seriously violates camp rules and evidence of the infraction can be found through a search of the camper’s personal belongings. To the extent possible, the camper will be present during such a search and the scope of the search shall be limited to their belongings. ________________________________________________

___________________

Parent/Guardian Signature:

Date:

Parent/Camper Confidential Form:

Assists our staff in ensuring a positive experience for each camper, parents are encouraged to help campers complete the camper section. Camper Section: What kind of things do you like to do?______________________________________________________________ Why do you want to go to camp?__________________________________________________________________ _____________________________________________________________________________________________ Camp will turn out to be a great experience if_________________________________________________________

Parent Section: How does your child react to new and different surroundings? ___________________________________________

What are your child’s regular duties or chores around the home?__________________________________________

In what manner have you found best to appropriately discipline your child?_________________________________

Has there been any stressful changes in your family this past year?________________________________________

Are there any limitations or other information your child’s camp counselor should be aware of?_________________

Does your child have any fears about camp?_________________________________________________________

Cabin “Buddy” Requests: Every effort will be made to place campers of the same gender and age together when requested at or prior to camp rally night. Please be aware that campers of different ages and siblings are not typically assigned to the same cabin group. Requests made after camp rally may not be possible. In addition to submitting this request, please talk to the Camp Director if your child may need help making new friends at camp. If you wish to request a specific cabin arrangement, please list your camper’s name, age, and grade along with the named, ages, and grade of up to three other campers. Please understand that “Buddy” requests will be completed and grouped according to the youngest aged “Buddy”. ___________________________________________________ Camper’s Full Name:

_______ Age:

_______

___________________________________________________ “Buddy” #1

_______ Age:

Grade:

___________________________________________________ “Buddy” #2

_______ Age:

Grade:

___________________________________________________ “Buddy” #3

_______ Age:

Grade: _______

_______

_______ Grade:

YMCA CAMP TA TA POCHON Health History Form *This Health History Form has to be filled out every year. The information on this form is not part of the camper or staff acceptance process. It is gathered to assist us in identifying appropriate care while at camp. This form should be completed by parents/guardians of minors or by adults themselves. Please keep a copy of the completed form for your records. Any changes to his form should be provided to the camp director upon the participant’s arrival at the bus or at camp. Please provide complete information so the camp can be aware of your or your child’s needs.

The following person is a/an

_____Camper

_____C.I.T

_____Adult Participant

Name: ___________________________________________________ Birthday date: __________ Age at camp ____ Last

First

Middle

Home Address: ______________________________________________________ Home Phone: _____________________ Street address

City

State

Zip

Social Security # of participant _________ -___________-_________ Gender: Male_____ Female______ Custodial Parent/Guardian__________________________________________ Home Phone: _________________________ Home Address: _______________________________________________________________________________________ (If different from above)

Street Address

City

Sate

Zip

Business Address: ____________________________________________________ Phone: ___________________________ Street Address

City

State

Zip

Second Parent or guardian or emergency contact: ____________________________________________________________ Address: ____________________________________________________________________________________________ Street Address

City

State

Zip

Business Address: _____________________________________________________________________________________ Street Address

City

If not available in an emergency, notify: Name: ________________________________________________________ Daytime phone:______________________________

State

Zip

Relationship: ________________________

Evening Phone:_____________________________

Address: ____________________________________________________________________________________________ Street Address

City

State

Zip

Insurance Information (A photocopy of front and back of health insurance card must be attached to this form) Is the participant covered by family medical/hospital insurance? Yes______

No______

If so, indicate carrier or plan name _____________________________ Group/Policy #_____________________________ Carrier Address_______________________________________________________________________________________ Name of Insured __________________________________________ Relationship to participant______________________ Social Security # of policy holder or insurance ID number ____________________________________________________

Important – The box below must be completed for attendance* *If for religious reason you cannot sign this, contact the camp for a legal waiver which must be signed for attendance

Permission to Provide Necessary Treatment or Emergency Care: I hereby give permission to the medical personnel selected by the Camp Director provide routine health care; to dispense medications, to order x-rays, routine test, treatment, to release any records necessary for insurance purposes, and to provide or arrange necessary related transportation for me or my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the Camp Director to secure and administer treatment, including hospitalization, order injection, anesthesia, or surgery for the person named above. I also give the camp permission to obtain a copy of my child’s health record from medical providers who treat my child and these providers may talk with the program’s staff about my child’s health status. This completed form may be photocopied for trips out of camp. Signature of parent/guardian or adult camper/staff________________________________________________________________ Witness_____________________________________________________________________ Date________________________

Allergies: List all known:

Medication allergies (list) ______________________ ______________________ ______________________ ______________________

Describe reaction and management of the reaction _____________________________________________ _____________________________________________ _____________________________________________ _____________________________________________

Food allergies (list) ______________________ ______________________ ______________________

_____________________________________________ _____________________________________________ _____________________________________________

Other allergies (list) – include insect stings, hay fever, asthma, animal dander, etc. ______________________ ______________________ ______________________

_____________________________________________ _____________________________________________ _____________________________________________

MEDICATION BEING TAKEN: Please list ALL medications (including over-the-counter or nonprescription drugs) taken routinely. Bring enough medication to last the entire time at camp. Keep it in the original packaging/bottle that identifies the prescribing physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration.

_______ This person takes NO medications on a routine basis.

________This person takes medication as follows: Med #1_____________________________________________ Dosage ______ Specific times taken each day ___________ Reasons for taking ____________________________________________________________________________________ Med #2_____________________________________________ Dosage ______ Specific times taken each day ___________ Reasons for taking ____________________________________________________________________________________ Med #3_____________________________________________ Dosage ______ Specific times taken each day ___________ Reasons for taking ____________________________________________________________________________________ Attach additional pages for more medications. Identify any medications taken during the school year that participant does/may take during the summer:________________

The following non-prescribed medications may be stocked in the locked medical cabin kept in the Health Center and are used as needed basis to manage illness and injury. Cross out and initial the medication the camper should not be given: Acetaminophen (Tylenol) ______ _ Ibuprofen (Advil, Motrin) Sore throat spray (generic) _______ Antihistamine/allergy medicine Cough drops(generic) _______ Diphenhydramine antihistamine/allergy medicine Calamine lotion _______ Cough syrup (Robitussin or generic) Aloe _______ Lice shampoo or cream (NIX, Ekimite, or generic) Antibiotic cream _______ Laxative for constipation (Ex-Lax or generic) Benadryl cream _______ Bismuth subsalicylate for diarrhea (Pepto-Bismol) Bacitracin _______ *Epi-Pen for unknown anaphylactic reactions (parent/guardian will be notified)

_______ _______ _______ _______ _______ _______ _______ _______

RESTRICTIONS: The following restrictions apply to this individual.

Dietary ____ Does not eat red meat ___ Does not eat pork ____ Does not eat seafood ___ Does not eat dairy products ___ Other: ___________________________________________

__Does not eat eggs ___Does not eat poultry __Does not eat meat because of religious reasons

Explain any restrictions to activity (e.g. what cannot be done, what adaptations or limitations are necessary)

Important – The box below must be completed for attendance. * I also understand and agree to abide by the restrictions placed on my camp activities. ___________________________________________________________ Signature of minor or adult camper/staff member

General Questions (explain “yes” answer below) Has/does the participant: Yes

No

1. Had any recent injury, illness, or infectious diseases?............ _____ _____ 2. Have a Chronic or recurring Illness/condition?................... _____ _____ 3. Ever been hospitalized?……... _____ _____ 4. Ever had surgery?……….. _____ _____ 5. Have frequent headaches?..... _____ _____ 6. Ever had head injury?............ _____ _____ 7. Ever been knocked unconscious?.... _____ _____ 8. Wear glasses, contacts, or Protective eyewear?........ _____ _____ 9. Ever had frequent ear infections? _____ _____ 10. Ever passed out during or after Exercise?........... _____ _____ 11. Ever been dizzy during or after Exercises?....... _____ _____ 12. Ever had chest pain during or after Exercise? _____ _____ 13. Ever had high blood pressure? _____ _____ 14. Ever been diagnosed with a heart Mumur? 15. Ever had back problems? _____ _____ 16. Ever had problems with joints ( e.g. knees, ankles, elbow, etc? _____ _____ 17. Have an orthodontic appliance being Brought to camp? _____ _____

_____________________ Date:

Yes

No

19. Have any skin problems(e.g itching, rash,acne)?............. _____ _____ 20. Have diabetes?....... _____ _____ 21. Have Asthma?……. _____ _____ 22. Had mononucleosis in the last 12 months?.................. _____ _____ 23. Had problems with diarrhea or constipation?........... _____ _____ 24. Have problems with sleepwalking?.... _____ _____ 26. If female, have problems with an abnormal menstrual history?___ _____ 27 Have a history of bedwetting?__ _____ 28.Have an eating disorder?. ._____ _____ 29. Ever had emotional difficulties for which professional help was sought? _____ ______

Please explain any “yes” answers from the page before, noting the number of the question. ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ __________________________________________________________________________________

Please give date for the last immunization for: Which of the following has the participant had? Date Vaccine __Measles __________________DTP __Chicken Pox __________________TD (Tetanus/diphtheria) __German Measles __________________Polio __Mump __________________Tetanus __Hepatitis __________________Measles (Hard or red __Varicella Zoster Measles or rubella) __________________Rubella ____________Date of last TB Mantoux test __________________Haemophilus influenza B Result______________________________ __________________Hepatitis B __________________Whooping cough __________________ Meningitis( Preteens & Teens)-recommended Use this space to provide any additional information about the participant’s behavior and physical, emotional, or mental health about which the camp should be aware. ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Name of family physician___________________________________ Phone___________________________ Address_________________________________________________________________________________ Name of family dentist/orthodontist____________________________Phone__________________________ Address_________________________________________________________________________________

Parent/Guardian Authorizations: This health history is correct and complete as far as I know, and the person herein described has permission to engage in all camp activities except as noted.

Sign:_______________________ Print Name:_______________________ Date:___________

YMCA CAMP TA TA POCHON Health Examination Form Parent or Guardian Please Complete This First Section For the following:

___Camper

___C.I.T

___Adult Participant

Name_________________________________Birthdate________________Age at Camp________ Last

First

Middle

Home Address_____________________________________________________________________ Street Address

City

State

Zip

Participant’s Home Phone #_________________________ Email Address____________________ Social Security Number of Participant___________________ Gender: Male____ Female ____ Custodial parent/guardian_______________________________Phone_______________________ Home Address_____________________________________________________________________ (if different above)

Street Address

City

State

Zip

Business Address_______________________________________Phone_______________________

***Following to be completed by a Licensed Medical Personnel Dear Doctor, Please be advised that this participant will be active in an outdoor camp at elevation of 6800 feet. They might have the possibility of hiking to an elevation of 11500 feet. Activities might include hiking, mountain biking, low ropes, swimming, canoeing, and utilizing a 20 foot climbing tower, etc. Please advise us of any limitations or concerns, or allergies. The use of this information will be kept confidential and be utilized by our camp medical staff and administrative staff for medical concerns and treatments only. Thank You. I have examined the above camp participant. Date of last examination_________________________ BP____________________

Weight___________________

In my opinion, the above Is______

Height___________________________

Is not______ able to participate in an active camp program.

The applicant is under the care of a physician for the following conditions: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Current treatment at the time of this report includes: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________

Recommendations and Restrictions at Camp: Treatment to be continued at camp: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Medications to be administered at camp (name, dosage, frequency) ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Medically prescribed meal plan or dietary restrictions: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Know allergies: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Description of any limitations or restriction of camp activities: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ Additional information for health care staff at camp: ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

Signature and Medical Office Stamp Are Required: Signature of Licensed Medical Personnel:____________________________________________________ Print Name: ____________________________________ Title:__________________________________ Address:______________________________________________________________________________ Phone__________________________________

Date___________________________

Please put your medical office or medical practitioner’s stamp here:

Print Childs Name:_______________________________________

For Camp Use Only Screening Record Date Screened_______________ Screened By___________________Time_______am pm Meds Received _________________________________________________________________________ _________________________________________________________________________ Updates/Additions To Health History Noted

___Yes

___No ___None Required

Current Health Needs Identified__________________________________________________________________ _________________________________________________________________________ Observational Notes_____________________________________________________________________ _________________________________________________________________________ Screener’s Signature________________________________________________________

YMCA of West San Gabriel Valley 401 East Corto Street * Alhambra, CA 91801 * (626)576-0226 * www.wsgvymca.org

Camp Ta TA Pochon Camper Information The information you enter into this form helps you child’s Cabin Leader learn as much as possible about your child before the session begins. We hope that this will help the Cabin Leader develop a quicker bond with the child thus enabling your child to feel comfortable at camp more quickly. Child’s full name_____________________________ Birth Date_______________ Nickname____________________ School you child attends_________________________________City______________________Grade_____________ Father’s Name_______________________________________Occupation____________________________________ Mother’s Name______________________________________Occupation____________________________________ Brothers?______________________

Ages__________

Are the parents living together?______________

Sisters?________________________ Ages____________

Has Child ever been away from home before?_____________

If so, where and how long?__________________________________________________________________________ Explain any fears or concerns your child may have about going to camp_______________________________________ ________________________________________________________________________________________________ What do you most desire for your child to get from attending camp?__________________________________________ ________________________________________________________________________________________________ What skills do you hope your child will develop at camp?__________________________________________________ Does your child know how to swim?________ If so, what is their level of proficiency?__________________________ What food does your child refuse to eat?________________________________________________________________ Please list any diet restrictions________________________________________________________________________ Does your Child have any allergies? (please list)_________________________________________________________ What duties or chores does your child have at home?______________________________________________________ W hat school subject(s) is your child most successful in?___________________________________________________ What hobbies does he or she have?____________________________________________________________________ What favorite activities does your child do with most of his/her spare time?____________________________________ ________________________________________________________________________________________________ Does your child normally associate with children their age?________________________________________________ Please list names of brothers, sisters, or friends who are at camp during the same session as your child______________ ________________________________________________________________________________________________

Does your child wish to be placed in a cabin with a specific sibling or friend?_____Who?________________________ What form of discipline usually works best with your child when they misbehave?______________________________ ________________________________________________________________________________________________ Does your child have any limitations which would impair their ability to participate in any camp activities?__________ Please explain:____________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Please explain any other tips or hints for working with your child and any thoughts or concerns you might have which could be of benefit to your child’s Cabin Leader_________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ Please list any other locations you might be during the camp session where we can reach you in an emergency other than what you have listed on the Health History Form. Day

Times

Location

Number

________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________